Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Non-small Cell Lung Cancer Staging: A Systematic Review and Metaanalysis

doi:10.1378/chest.06-1437

Chest

Volume 131, Issue 2, February 2007, Pages 539-548

https://doi.org/10.1378/chest.06-1437 Get rights and content

Abstract

Background:Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive alternative technique for mediastinal staging of non-small cell lung cancer. A metaanalysis was performed to estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in patients with lung cancer.

Methods:Relevant studies were identified using Medline (1966 to November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow-up (> 6 months) as the “gold standard,” and provided sufficient data for calculating sensitivity and specificity. Summary receiver operating characteristic curves metaanalysis was performed to estimate the pooled sensitivity and specificity.

Results:In 18 eligible studies, EUS-FNA identified 83% of patients (95% confidence interval [CI], 78 to 87%) with positive mediastinal lymph nodes (pooled sensitivity) and 97% of patients (95% CI, 96 to 98%) with negative mediastinal lymph nodes (pooled specificity). In eight studies that were limited to patients who had abnormal mediastinal lymph nodes seen on CT scans, the sensitivity was 90% (95% CI, 84 to 94%) and the specificity was 97% (95% CI, 95 to 98%). In patients without abnormal mediastinal lymph nodes seen on CT scans (four studies), the pooled sensitivity was 58% (95% CI, 39 to 75%). Minor complications were reported in 10 cases (0.8%). There were no major complications.

Conclusions:EUS-FNA is a safe modality for the invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to mediastinal lymph nodes seen on CT scans. In addition, among lung cancer patients with normal mediastinal adenopathy seen on CT scans, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT scanning.

Section snippets

Study Selection and Data Abstraction

A literature search was performed using PubMed and CINAHL from January 1966 to November 2005. The following search terms were used: endoscopic ultrasound OR endosonography; and biopsy, fine-needle OR fine-needle aspiration. Titles and abstracts were reviewed by two independent investigators (CGM and DAP). Full articles of appropriate studies were retrieved for detailed evaluation. We included studies in any language that included the following; (1) used EUS-FNA in adult patients (> 18 years

Results

Combining the search terms resulted in a total of 101 articles (^{Fig 1}). Seventy-seven articles were excluded after reviewing the title and abstract. Eight articles were excluded after reviewing the full article.7, 8, 9, 10, 11, 12, 13, 14Two additional studies15, 16were identified from the references of articles obtained from this literature search and review articles.

A total of 18 studies15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32were included in the metaanalysis (

Discussion

In this metaanalysis, we found that EUS-FNA is an accurate method for the invasive staging of NSCLC. Its sensitivity is higher when used to confirm metastasis to lymph nodes in patients with suspected N2 or N3 disease seen on CT scans. Patients without enlarged mediastinal adenopathy seen on CT scans had a 35% prevalence of malignant mediastinal lymph nodes. The performance of EUS-FNA in this group is useful given the ability of this technique to sample nodes as small as 3 mm and to identify

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Application of rapid on-site evaluation combined with flexible bronchoscopy in the diagnosis of lung lesions
2024, Annals of Diagnostic Pathology
Pathology is considered the gold standard for the diagnosis of lung lesions, but the pathological result is relatively lagging and cannot provide real-time guidance for the biopsy procedure.
To investigate the potential application of rapid on-site evaluation (ROSE) during flexible bronchoscopy (FB) in the evaluation and diagnosis of lung lesions.
Consecutive patients who underwent FB for the diagnosis of lung lesions between August 2022 and February 2023 were included in this retrospective study. 294 patients underwent FB with ROSE, while 304 patients underwent FB without ROSE. The final pathological results and the number of patients undergoing repeat biopsies were recorded in both groups. Specifically, we conducted separate statistical analysis for patients undergoing different biopsy methods, including the endobronchial biopsy (EBB), radial probe endobronchial ultrasound transbronchial lung biopsy with guide sheath (r-EBUS-GS-TBLB), and the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to study the detailed roles that ROSE plays under different biopsy methods.
The adequacy rate of biopsy specimens from the non-ROSE group was significantly lower than that of the ROSE group (259/281 = 92.17 % vs. 263/268 = 98.13 %, p = 0.001). Meanwhile, fewer patients underwent repeat biopsies in the ROSE group compared to the non-ROSE group (2/294 = 0.68 % vs. 10/304 = 3.29 %, p = 0.023). For the ROSE group, the consistency between ROSE diagnoses and final pathological diagnoses was 94.40 % (κ = 0.886), with 95.58 % for benign diseases and 93.55 % for malignant diseases.
The utility of ROSE during FB increases the adequacy rate of biopsy specimens and thus decreases the need for repeat biopsies in patients with lung lesions to get a definite diagnosis. Moreover, the high consistency between ROSE diagnoses and final pathological diagnoses suggests that ROSE is a reliable tool for optimizing the diagnosis of lung lesions.
Bilan d'extension du cancer bronchique et classification TNM des CBNPC
2023, Revue des Maladies Respiratoires Actualites
Le diagnostic de certitude de cancer du poumon repose sur l’examen anatomopathologique. Les prélèvements tissulaires (par biopsie), ou cellulaires (par lavage, cytoponction) sont réalisés à partir de la tumeur, des adénopathies associées ou d’un site métastatique accessible. Il existe différentes méthodes d’abord diagnostique d’une opacité suspecte de cancer bronchique. Des recommandations pour chacune des techniques ont été émises afin d’en maximiser le rendement diagnostique et de permettre des analyses immunohistochimiques ou de biologie moléculaire ou qui modifient la stratégie thérapeutique. Le premier objectif de ce propos est d’exposer les différentes méthodes diagnostiques et de proposer des pistes pour optimiser le diagnostic des cancers broncho-pulmonaires.
Définir le cTNM repose sur un bilan précis et rigoureux. Le second objectif de cet article est de présenter les modalités du bilan d’extension des CBNPC, en abordant les indications des examens d’imagerie ainsi que leurs limites. Le bilan des CPC est traité dans un chapitre spécifique. L’examen clinique reste essentiel. Le scanner thoracique avec injection de produit de contraste iodée est systématique, sauf contre-indication. La taille de la tumeur, son extension pleurale, pariétale, endobronchique et médiastinale directe doivent être précisées de même que l’extension ganglionnaire. La TEP-TDM au 18FDG n’est pas indiquée en première intention mais elle est indispensable chez les patients potentiellement éligibles à un traitement curatif. L’imagerie cérébrale est indiquée, même chez les patients asymptomatiques. Le respect des recommandations et une organisation adéquate optimisent la prise en charge des patients. La classification internationale TNM, acceptée conjointement par l’UICC et l’AJCC est utilisée en routine pour les cancers bronchiques non à petites cellules. Le but de cet article est de présenter la 8^e classification TNM, son implication en pratique ainsi que les propositions émanant du IASLC Staging Committee concernant certaines situations cliniques particulières. La base de données qui va servir à l’élaboration de la 9^ème classification est décrite en attendant la publication de la.prochaine révision
1877-1203/© 2023 SPLF. Publié par Elsevier Masson SAS. Tous droits réservés.
The definitive diagnosis of lung cancer relies on pathological examination. Tissue samples (by biopsy), or cell samples (by washing, cytopuncture) are collected from the tumor, associated lymphadenopathy or from an accessible metastatic site. There are different methods of diagnostic access to an opacity suspect of bronchial cancer. Guidelines have been published for each of the techniques in order to maximize their diagnostic efficiency and to allow or immunohistochemical or molecular analyses that modify the therapeutic strategy. The first objective of this topic is to describe the different diagnostic methods and to suggest ways to optimize the diagnosis of broncho-pulmonary cancers.
Establishing cTNM relies on a precise and rigorous evaluation. The second objective of this article is to present the modalities of NSCLC extension assessment, addressing the indications of imaging exams as well as their limitations. SCLC management is discussed in a specific chapter. Clinical examination remains essential. Chest Computed- Tomography (CT) scan with iodine contrast injection is systematic, unless contraindicated. The size of the tumor, its pleural, parietal, endobronchial and direct mediastinal extension should be specified as well as the lymph node extension. 18FDG PET-CT is not indicated as a first line but is essential in patients potentially eligible for curative treatment. Brain imaging is indicated, even in asymptomatic patients. Compliance with the recommendations and proper organisation optimise management of patients.
The international TNM classification, accepted by both UICC and AJCC, is routinely used for non-small cell lung cancer management. The aim of this article is to review the 8^th TNM classification, its practical implications and the IASLC Staging Committee proposals regarding some specific clinical situations. The new database that will inform the ninth TNM classification is discribed awiating publication of the next revision.
1877-1203/© 2023 SPLF. Published by Elsevier Masson SAS. All rights reserved.
The yield and impact of pulmonologist-performed EUS-B-FNA of subdiaphragmatic lesions—an institutional experience
2023, Journal of the American Society of Cytopathology
Pulmonologists can biopsy structures below the diaphragm using the convex curvilinear ultrasound bronchoscope via the esophagus (EUS-B). The literature with respect to the value of EUS-B, rapid on-site evaluation, and final diagnostic yield for structures below the diaphragm is limited. We review our institutional experience.
Our database was queried retrospectively for EUS-B fine needle aspirations (FNAs) from 2013 to 2021. All procedures involving EUS-B-FNA of subdiaphragmatic structures were selected for analysis. The following data elements were collected for each patient: age, gender, clinical indication, sample site, on-site adequacy (OSA), preliminary and final diagnoses, and sufficiency of cell block for ancillary studies.
A total of 75 subdiaphragmatic sites were biopsied in 74 patients. Of which, 87% of samples subjected to rapid on-site evaluation were deemed to contain adequate material (OSA+). There were no false-positive OSAs. Six cases remained nondiagnostic at the final diagnosis. The final diagnostic yield (with cell block) was 92% (69/75 cases). Cell block was sufficient for immunohistochemistry or special stains in all applicable cases (n = 36). Molecular testing was requested for 11 cases and successful in 10 (91%). Sampling of subdiaphragmatic sites changed the stage in 67% (38/57) of lung cancer patients.
Pulmonologists can perform EUS-B-FNA of subdiaphragmatic sites with high OSA and final diagnostic yield when assisted by cytopathologists. Strong correlations exist between OSA, cell block adequacy, and subsequent capacity to perform ancillary testing. EUS-B below the diaphragm can make an important contribution to the diagnosis of lung cancer, nonpulmonary malignancies, and other diseases.
Bilan du cancer broncho-pulmonaire non à petites cellules : quel bilan anatomique ?
2022, Revue des Maladies Respiratoires Actualites
Le diagnostic de certitude de cancer du poumon repose sur l’examen anatomopathologique. Les prélèvements tissulaires (par biopsie), ou cellulaires (par lavage, cytoponction) sont réalisés à partir de la tumeur, des adénopathies associées ou d’un site métastatique accessible. Il existe différentes méthodes d’abord diagnostique d’une opacité suspecte de cancer bronchique. Des recommandations pour chacune des techniques ont été émises afin d’en maximiser le rendement diagnostique et de permettre des analyses immunohistochimiques ou de biologie moléculaire qui modifient la stratégie thérapeutique. Le premier objectif de ce propos est d’exposer les différentes méthodes diagnostiques et de proposer des pistes pour optimiser le diagnostic des cancers broncho-pulmonaires.
Définir le cTNM nécessite un bilan précis et rigoureux. Le second objectif de cet article est de présenter les modalités du bilan d’extension des CBNPC, en abordant les indications des examens d’imagerie ainsi que leurs limites. L’examen clinique reste essentiel. Le scanner thoracique avec injection de produit de contraste iodée est systématique. La taille de la tumeur, son extension pleurale, pariétale, endobronchique et médiastinale directe doivent être précisées de même que l’extension ganglionnaire. La TEP-TDM au 18FDG n’est pas indiquée en première intention mais est indispensable chez les patients potentiellement éligibles à un traitement curatif. L’imagerie cérébrale est indiquée, même chez les patients asymptomatiques. Le respect des recommandations et une organisation adéquate optimisent la prise en charge des patients.
1877-1203/© 2022 SPLF. Publié par Elsevier Masson SAS. Tous droits réservés.
The definitive diagnosis of lung cancer relies on pathological examination. Tissue samples (by biopsy), or cell samples (by washing, cytopuncture) are collected from the tumor, associated lymphadenopathy or from an accessible metastatic site. There are different methods of diagnostic access to an opacity suspect of bronchial cancer. Guidelines have been published for each of the techniques in order to maximize their diagnostic efficiency and to allow either immunohistochemical or molecular analyses that modify the therapeutic strategy. The first objective of this topic is to describe the different diagnostic methods and to suggest paths to optimize the diagnosis of broncho-pulmonary cancers. Establishing cTNM relies on a precise and rigorous evaluation.
The second objective of this article is to present the modalities of NSCLC extension assessment, addressing the indications of imaging exams as well as their limitations. Clinical examination remains essential. Chest Computed-Tomography (CT) scan with iodine contrast injection is systematic. The size of the tumor, its pleural, parietal, endobronchial and direct mediastinal extension should be specified as well as the lymph node extension. ¹⁸FDG PET-CT is not indicated frontline, but is essential in patients potentially eligible for curative treatment. Brain imaging is indicated, even in asymptomatic patients. Compliance with such recommendations and proper organisation is needed to optimise patients management.
1877-1203/© 2022 SPLF. Published by Elsevier Masson SAS. All rights reserved.
All-in-focus fine needle aspiration biopsy imaging based on Fourier ptychographic microscopy
2022, Journal of Pathology Informatics
Cytology is the study of whole cells in diagnostic pathology. Unlike standard histologic thinly sliced specimens, cytologic preparations consist of preparations of whole cells where cells commonly cluster and aggregate. As such, cytology preparations are generally much thicker than histologic slides, resulting in large patches of defocus when examined under the microscope. A diagnostic aggregate of cells often cannot be viewed in focus together, requiring pathologists to continually manipulate the focal plane, complicating the task of accurately assessing the entire cellular aggregate and thus in making a diagnosis. Further, it is extremely difficult to acquire useful uniformly in-focus digital images of cytology preparations for applications such as remote diagnostic evaluations and artificial intelligence models. The predominant current method to address this issue is to acquire digital images at multiple focal planes of the entire slide, which demands long scanning time, complex and expensive scanning systems, and huge storage capacity.
Here we report a unique imaging method that can acquire cytologic images efficiently and computationally render all-in-focus digital images that are highly compact.
This method applies a metric-based digital refocusing to microscopy data collected with a Fourier ptychographic microscope (FPM). The digitally refocused patches of images are then synthesized into an all-in-focus image.
We report all-in-focus FPM results of thyroid fine needle aspiration (FNA) cytology samples, demonstrating our method’s ability to overcome the height variance of 30 μm caused by cell aggregation, and rendering images at high resolution (corresponds to a standard microscope with objective NA of 0.75) and that are all-in-focus.
This technology is applicable to standard microscopes, and we believe can have an impact on diagnostic accuracy as well as ease and speed of diagnosing challenging specimens. While we focus on cytology slides here, we anticipate this technology’s advantages will translate well for histology applications. This technique also addresses the issue of remote rapid evaluation of cytology preparations. Finally, we believe that by resolving the focus heterogeneity issues in standard digital images, this technique is a critical advance for applying machine learning to cytology specimens.
Endosonography with lymph node sampling for restaging the mediastinum in lung cancer: A systematic review and pooled data analysis
2020, Journal of Thoracic and Cardiovascular Surgery
Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration for restaging the mediastinum after induction treatment in patients with lung cancer.
Embase and PubMed databases were searched from conception to March 2019. Data from relevant studies were analyzed to assess sensitivity and specificity of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration, and to fit the hierarchical summary receiver operating characteristic curves.
A total of 10 studies consisting of 558 patients fulfilled the inclusion criteria. All patients were restaged by endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration, or both. Negative results were confirmed by subsequent surgical approaches. There were no complications reported during any endosonography approaches reviewed. The pooled sensitivities of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration were 65% (95% confidence interval [CI], 52-76) and 73% (95% CI, 52-87), respectively, and specificities were 99% (95% CI, 78-100) and 99% (95% CI, 90-100), respectively. The area under the hierarchical summary receiver operating characteristic curves were 0.85 (95% CI, 0.81-0.88) for endobronchial ultrasound-guided transbronchial needle aspiration and 0.99 (95% CI, 0.98-1) for endoscopic ultrasound-guided fine-needle aspiration. Moreover, for patients who received chemotherapy alone, the pooled sensitivity of endosonography with lymph node sampling for restaging was 66% (95% CI, 56-75), and specificity was 100% (95% CI, 34-100); for patients who received chemoradiotherapy, the results seemed similar with a sensitivity of 77% (95% CI, 47-92) and specificity of 99% (95% CI, 48-100).
Endosonography with lymph node sampling is an accurate and safe technique for mediastinal restaging of lung cancer.

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The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

Original Research: Interventional PulmonologyEndoscopic Ultrasound-Guided Fine-Needle Aspiration for Non-small Cell Lung Cancer Staging: A Systematic Review and Metaanalysis

Abstract

Section snippets

Study Selection and Data Abstraction

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Chest

Lung Cancer

Ann Thorac Surg

Lung Cancer

Gastrointest Endosc

Gastrointest Endosc

Lung Cancer

Am J Respir Crit Care Med

Ann Thorac Surg

Chest

Ann Thorac Surg

Chest

Ann Thorac Surg

Chest

Chest

Gastrointest Endosc

Original Research: Interventional Pulmonology
Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Non-small Cell Lung Cancer Staging: A Systematic Review and Metaanalysis